Hoping for hepatitis C elimination
Authors: None The Lancet Microbe
Journal: The Lancet Microbe (2023)

In March an initiative was proposed in the USA to eliminate hepatitis C, a disease that is eminently treatable if structural barriers can be overcome. Unfortunately, this is a disease that significantly impacts populations underprioritised, or not prioritised at all, by US politics: people with low incomes, who are incarcerated, or who inject drugs. Striking evidence of this lack of priority in the USA can be seen in the proportion of those cured (one in three) despite the availability of very effective treatments for a decade. However, access to treatment is not the only factor limiting the number of people being cured. Currently, diagnosis in the USA is a complicated process that creates further barriers for populations that already find accessing health care problematic. The proportion of people in the USA cured of hepatitis C was determined through the piecing together of the hepatitis C virus elimination cascade from 2013 by the US Centers for Disease Control and Prevention. Delving deeper into the findings of this analysis unsurprisingly shows that ability to pay closely aligns with access to curative treatment. These findings support the argument for a centrally funded initiative in the USA. The benefits of elimination will be far-reaching, not only saving lives, but also money. However, the need for upfront investment is where ambitious plans like this often falter. Elsewhere in the world, alternative approaches were put in place to overcome cost as a barrier to treatment. Encouraging news for the tackling of hepatitis C globally was the announcement in May of Memoranda of Understanding to lower the price of prequalified drugs in low-income and middle-income countries by at least 90%. The anticipation is that this announcement brings WHO's commitment to the elimination of viral hepatitis by 2030 a step closer. The urgency of this commitment is underpinned by projections that viral hepatitis could become the leading cause of infectious disease-related deaths by 2040. In an Article in this issue of The Lancet Microbe, Jelle Koopsen and colleagues explore a further potential complication to elimination efforts: the transmission of hepatitis C viruses that have resistance-associated substitutions. Fortunately, viruses with these substitutions do not currently represent a threat to elimination, at least not in men who have sex with men who were the study population, but ongoing vigilance will be essential. Koopsen and colleagues advise, given the risks to elimination they outline, that internationally coordinated surveillance will be needed to realise the 2030 elimination goal. Further encouraging news is recent work uncovering how hepatitis C virus RNA evades protective mechanisms directed at foreign RNA. This evasion involves capping the viral RNA with flavin adenine dinucleotide, which acts to mask the RNA from innate defences. Although this capping is a known protective strategy for RNA viruses, this is the first time it has been identified in hepatitis C virus. This insight potentially opens avenues for the development of new treatments because, as outlined in the work of Koopsen and colleagues, drug resistance is a constant threat to plans of disease elimination. A crucial point, certainly not lost on the readers of The Lancet Microbe, is that elimination of hepatitis C, and viral hepatitis more broadly, will require more than the dispensing of drugs. It will require the furthering of our understanding of the causative viruses both in terms of the properties of the viruses and their movement through human populations. Since elimination is not eradication, this fundamental work will be needed to avoid the erosion of any potential successes. However, it is unclear whether funding work of this nature is factored into elimination efforts. We can see from the activity outlined above that research in hepatitis C virus and its impact is yielding valuable insights that bring the ambition of elimination ever closer. However, the limits of this ambition will ultimately be political rather than technical. Will politicians summon the will, both within the USA and elsewhere, to see the job through to disease elimination? Despite the threat posed and the ambitious targets, viral hepatitis is an area that remains neglected and underfunded. To prompt policy makers around the world the call to action for World Hepatitis Day on July 28 was “We’re not waiting”. Elimination of hepatitis C is within reach if authorities can be encouraged to look beyond immediate costs to long-term benefits. Hepatitis C virus transmission between eight high-income countries among men who have sex with men: a whole-genome analysisDespite antiviral treatment becoming widely available, international transmission of HCV among MSM has still occurred over the past 8 years, which could complicate microelimination of the virus in this population. RAS-enriched clusters and widespread RAS transmission are currently not a threat to elimination goals. These findings support an international approach for HCV microelimination among MSM. Full-Text PDF Open Access